Quality of life in patients with resectable rectal cancer during the first 24 months following diagnosis

AIM

An increasing number of patients survive rectal cancer, resulting in more patients living with the side-effects of the treatment. Exploring quality of life before and after treatment enables follow-up and additional treatment to be adjusted to the patient's needs. The aim of the study was to describe the quality of life during the 24 months following diagnosis and to identify risk factors for poor quality of life.

METHOD

This is a prospective cohort study of patients with rectal cancer followed up by extensive questionnaires. Patients from 16 surgical departments in Denmark and Sweden from 2012 to 2015 were included. The self-assessed quality of life was measured with a seven-point Likert scale.

RESULTS

A total of 1110 patients treated with curative intent were included, and the response rate at the 24-month follow-up was 71%. Patients with rectal cancer assessed their quality of life before start of treatment as poorer than that of a reference population. At the 12- and 24-month follow-up, the quality of life on group level had recovered to the same level as for the reference population. Risk factors for poor quality of life included bother with urinary, bowel and stoma function. A reference population was used for comparison.

CONCLUSION

The quality of life of patients with resectable rectal cancer recovered to levels comparable to a reference population 12 and 24 months after diagnosis. Our results indicate that the urinary, bowel and stoma function has an impact on quality of life.

Low anterior resection syndrome in a Scandinavian population of patients with rectal cancer: a longitudinal follow-up within the QoLiRECT study

AIM

Low anterior resection syndrome (LARS) is common after low anterior resection. Our aim was to evaluate the prevalence and 'bother' (subjective, symptom-associated distress) of major LARS after 1 and 2 years, identify possible risk factors and relate the bowel function to a reference population.

METHOD

The QoLiRECT (Quality of Life in RECTal cancer) study is a Scandinavian prospective multicentre study including 1248 patients with rectal cancer, of whom 552 had an anterior resection. Patient questionnaires were distributed at diagnosis and after 1, 2 and 5 years. Data from the baseline and at 1- and 2-year follow-up were included in this study.

RESULTS

The LARS score was calculated for 309 patients at 1 year and 334 patients at 2 years. Prevalence was assessed by a generalized linear mixed effects model. Major LARS was found in 63% at 1 year and 56% at 2 years. Bother was evident in 55% at 1 year, decreasing to 46% at 2 years. Major LARS was most common among younger women (69%). Among younger patients, only marginal improvement was seen over time (63-59%), for older patients there was more improvement (62-52%). In the reference population, the highest prevalence of major LARS-like symptoms was noted in older women (12%). Preoperative radiotherapy, defunctioning stoma and tumour height were found to be associated with major LARS.

CONCLUSION

Major LARS is common and possibly persistent over time. Younger patients, especially women, are more affected, and perhaps these patients should be prioritized for early stoma closure to improve the chance of a more normal bowel function.

Self-reported sexual dysfunction in patients with rectal cancer

AIM

Patients with rectal cancer often experience sexual dysfunction after treatment. The aim of this study was to evaluate sexual function in a prospective cohort of patients regardless of treatment and tumour stage and explore what factors might affect sexual activity 1 year after diagnosis.

METHOD

The QoLiRECT study (Quality of Life in RECTal cancer) is a prospective study on the health-related quality of life in patients with rectal cancer in Denmark and Sweden. Questionnaires were completed at diagnosis and 1 year. Clinical data were retrieved from national quality registries.

RESULTS

Questionnaire data were available from 1085 patients at diagnosis and 920 patients at 1 year. Median age was 69 years (range 25-100). At diagnosis, 29% of the women and 41% of the men were sexually active, which was lower than an age-matched reference population. This was further reduced to 25% and 34% at 1 year. Risk factors for sexual inactivity were absence of sexual activity prior to the diagnosis and the presence of a stoma. Women experienced reduced lubrication and more dyspareunia at 1 year compared with the time of diagnosis. In men, erectile dysfunction increased from 46% to 55% at 1 year.

CONCLUSION

Sexual activity in patients with rectal cancer is lower at diagnosis compared with the population norm and is further reduced at 1 year. The presence of a stoma contributed to reduced sexual activity after operation. Sexual dysfunction was difficult to evaluate due to low sexual activity in the cohort. In men, erectile dysfunction is common.

Urinary dysfunction in patients with rectal cancer: a prospective cohort study

AIM

Urinary dysfunction is one of many complications after treatment for rectal cancer. The aim of this study was to evaluate the prevalence of patient-reported urinary dysfunction at the time of diagnosis and at 1-year follow-up and to assess the risk factors linked to urinary incontinence.

METHOD

Patients with newly diagnosed rectal cancer were included in the QoLiRECT study between 2012 and 2015. Questionnaires from the time of diagnosis and 1-year follow-up were analysed, with 1085 and 916 patients, respectively, eligible for analysis. Regression analyses were made to investigate possible risk factors for incontinence. The patient cohort was also compared with a cohort from the Swedish general population.

RESULTS

At baseline, the prevalence of urinary dysfunction (14% of women, 8% of men) was similar to that in the general population. At 1-year follow-up, 20% of patients experienced urinary incontinence (29% of women, 14% of men). Emptying difficulties were experienced by 46% (41% of women, 49% of men) and urgency by 58% across both sexes. Abdominoperineal excision and urinary dysfunction at baseline were found to be independent risk factors for incontinence at 1-year follow-up. Among patients who were continent at baseline, risk factors were female sex, physical inactivity at baseline, comorbidity and abdominoperineal excision.

CONCLUSION

Urinary dysfunction is frequent among patients with rectal cancer, with up to a two-fold increase in symptoms 1 year after diagnosis. Unfortunately, few factors are modifiable and these results stress the importance of informing patients of possible outcomes related to urinary dysfunction after treatment for rectal cancer.

Outcome of extralevator abdominoperineal excision compared with standard surgery: results from a single centre

AIM

Extralevator abdominoperineal excision (APE) for low rectal tumours has been introduced to achieve improved local radicality. Fewer positive margins and intraoperative perforations have been reported compared with standard APE. The aim of this retrospective study was to compare short-term complications and results of the two techniques in our institution.

METHOD

Consecutive patients with rectal cancer undergoing APE between 2004 and 2009 were included. They were divided into two groups of 79 patients in extralevator APE and 79 in standard APE. Patients with recurrence and those having a palliative procedure were excluded. Data were collected from hospital records and the colorectal cancer registry. Main endpoints were wound infection, perineal wound revision, oncological data and length of hospital stay.

RESULTS

Circumferential resection margin positivity did not differ significantly between groups (17% extralevator APE; 20% standard APE). Intraoperative perforation (13%vs 10%) or local recurrence (seven in each group) were no different. Perineal wound infection was more common after extralevator APE (46%vs 28%, P<0.05) as was perineal wound revision (22%vs 8%, P<0.05). Hospital stay was longer after extralevator APE (median 12 vs 11days, P<0.05). Tumour height (median 4cm) and pTNM classification did not differ.

CONCLUSION

The results do not show any advantage for extralevator APE. The oncological data were no better and postoperative morbidity was increased. Further studies are needed before extralevator APE is widely adopted in clinical practice.

Reaction of mucochloric and mucobromic acids with adenosine and cytidine: formation of chloro- and bromopropenal derivatives

Mucochloric (MCA) and mucobromic acid (MBA)--bacterial mutagens and water disinfection byproducts--were reacted with adenosine, cytidine, and guanosine in N,N-dimethylformamide (DMF). In the MCA reaction with adenosine and cytidine and in the MBA reaction with adenosine one major product was formed. In the reactions of MBA with cytidine and in the reactions of MCA and MBA with guanosine only trace levels of products could be detected, and these were not further characterized. The products from the adenosine and cytidine reactions were isolated by preparative chromatography on octadecylsilane columns and structurally characterized by UV absorbance, 1H and 13C NMR spectroscopy, and mass spectrometry. The products were identified as 3-(N6-adenosinyl)-2-chloro-2-propenal (MClA), 3-(N6-adenosinyl)-2-bromo-2-propenal (MBrA), and 3-(N4-cytidinyl)-2-chloro-2-propenal (MClC). The yields of MClA, MBrA, and MClC were 19, 4 and 7 mol %, respectively. These halopropenal derivatives were formed also in reactions carried out in aqueous solutions at pH 7.4 and 37 degrees C at low yields, about 5 x 10(-3)%. The mechanism of formation of the halopropenal derivatives and of the previously identified etheno and ethenocarbaldehyde derivatives was elucidated by reacting 13C-3 labeled MCA with adenosine in DMF and in water. The location of the labeled carbon in the products was determined from the 13 C NMR spectra. It was concluded that the halopropenal derivatives were formed by mechanisms that differ completely from the one responsible for the formation of the propenal adducts (M1A and M1C) previously reported to be formed in reactions of malonaldehyde with adenosine and cytidine.

Reaction of mucochloric acid with adenosine: formation of 8-(N6-adenosinyl)ethenoadenosine derivatives

The bacterial mutagen mucochloric acid was reacted with adenosine in aqueous solutions at 37 degrees C. In the HPLC chromatograms of the reaction mixtures two peaks of unidentified products were observed at longer retention times than the previously characterized "etheno" and "ethenocarbaldehyde" adducts. Following isolation and purification with chromatographic methods, the products were characterized by UV absorbance, 1H and 13C NMR spectroscopy, and thermospray mass spectrometry. The products were found to consist of ethenoadenosine derivatives which bonded an additional adenosine unit to C-8 in the etheno bridge. In one of the products a formyl group and in the other an oxalo group was localized at C-7 in the etheno bridge. The yield of the products was about 0.04 mol% (calculated from the original amount of adenosine) in the reaction mixture held for 4 days at pH 7.4. It was concluded that mucochloric acid acts as an oxidative agent during the course of formation of the products.